He's Having A Heart Attack, Where's My Tourniquet?

Napping Street Vendor in Amman

When was the last time that a domestic executive protection detail had to provide medical care while under  attack?  I'm open to input, but I can't think of a single instance.  Then why are protectors so hell-bent on spending money and time on learning tactical medicine, i.e. providing medical care while under fire?  The answer is that it's fun and sexy, but the hard truth is that it's useless for domestic details.

I'm not saying that tactical medicine does not have it's place, but that place is on SWAT teams, and in military and other high risk environments, not on U.S.-based executive protection details. Security details and contracting protecters are waisting their time and money pursuing those skills.

What kills?  In other words, if you were pushed into any emergency room which common afflictions are going to get you seen right now by an anxious physician because your life is in immediate danger? They are:

• Myocardial infarction (heart attack)
• Active seizures
• Suspected cerebral vascular attack (stroke)
• Airway compromise:
• Anaphylaxis (allergic reaction)
• Foreign body (choking)
• Pulmonary embolism (not a true airway compromise though)
• Severe asthma attack
• Hypoglycemic coma
• Severe trauma

That's it, everything else can wait.  Take a seat in the waiting room.

How many of these afflictions are discussed in your tactical medicine course?  Trauma of course, but only as it applies to gunshots wounds while under fire, which, as noted, are exceedingly rare.  The rest, which are infinitely more common, are going to kill your client while you stand by with tourniquet and QuikClot in-hand. 

Eyebrow-to-Eyebrow

Soon I will start doing some patient care as a paramedic again.  Its been several months since I've practiced, and I've truly missed the experience of caring for patients.  Medicine, for many years, has been a large part of my life and I'm very excited to be practicing once again.

As a Zen Buddhist I try to seek ways to better the world that we live in.  Some are drawn to activism as a tool, attempting to bring change on a larger scale such as the Occupy Movement.  Others, like myself, look to service as a skillful means of helping humanity, working "eyebrow-to-eyebrow" with one person at a time; attempting to make a difference in that person's life or even death.  

I believe that there are few greater places on earth to practice compassion than an inner-city emergency room.  The opportunities are boundless to check your 'ego at the door' and truly help those that believe that they're in need.  

Forgiveness

Not long ago I was the lead paramedic on a cardiac arrest of an elderly woman who had collapsed in her home.  When I arrived the woman's frantic son was looking on as two fire department paramedics and an EMT were starting CPR and additional advanced life-support treatments.  I could see the terror in his eyes as his mother lay on her back in the middle of her living room.  He paced back and forth asking questions, looking to do anything that he could to help, to make a difference.

As the lead paramedic this was my scene to control and orchestrate; decisions were made and treatments started according to the very latest in resuscitation literature and guidelines.  The woman was placed in the ambulance with ongoing good CPR by one of the EMTs; rhythm strips, IV's, drugs, endotracheal tube, shocks, more drugs.  Despite our efforts the woman wasn't responding and was pronounced shortly after our arrival at the hospital.

Sitting alone in the ambulance I worked on my report trying to remember the details of the call.  Quickly I became hyper-critical of my performance, thinking about what I could have done differently, anything that would have led to a better outcome.  I beat myself up for several minutes going over the events in my mind, until finally I looked down at my clipboard and saw the woman's smiling face on her drivers license staring up at me.  I remembered that I had hastily grabbed the card from her son so that at least I would have a name when I arrived at the hospital.  She smiled at me as if to say, "Hey you did the very best that you could, so stop beating yourself up".  In a moment I realized that the call wasn't about me and my performance but rather the woman who was somehow forgiving me, smiling from a piece of plastic.  I pushed my report aside and strode back into the hospital to seek out her son.  I think that's what she would have wanted me to do.

Caracas Emergency Department

A final word on moto-taxis.  No, this is not me on the back.  There are so many of these things whizzing around that an inspiring photographer could make a collection of shots like this.

Last night I toured a Caracas Emergency Department and I've come to the conclusion that most third-word hospitals are the same: short on supplies and long on sick people.  The entrance to the building had all the charm of an East German jail, complete with bars, a sleepy guard, stained tiled floors, and blinking florescent lights. Continuing through the waiting room there was the normal cast of the sick and sleeping laid out on cold metal benches oblivious to one another.

When I walked into the ER all I could see was rows of beds behind a single, long curtain.  Every patient had an IV drip, which I took to be a good sign, but my optimism ended there.  No gloves or masks for the staff, shockingly limited medications, blood-stained floors and sheets, and some of the worse X-rays I've ever seen. 

I spoke with some of my colleagues, pointing some things out and cautioning them not to judge too harshly.  The hospital staff was clearly doing the best that it could with what meager supplies the State had given them. I spoke with the attending physician, he quietly detailed of the nightly struggles to make due with what he was given.  The nurses sang the same tune, each day the staff had to make decisions about which patients got what was left of the dwindling supplies.  This was not a place to be sick, and I couldn't help but hearken back to my death-defying moto-taxi ride that morning.  If we had had an accident, this is where I would have ended up, possibly for good.

The Buddhist Paramedic- Deepening Compassion

A mountain-top antenna extends skyward through the clouds and mist.

I was approached on Facebook by a Zen Buddhist priest who asked me about becoming involved in Emergency Medical Services (EMS) as a future vocation.  The conversation is still ongoing but its one that I'm very excited to have.  I can think of no other job that will deepen a Buddhist practice more so than EMS; I say that with a bit of a sarcastic undertone.

If you stay in EMS long enough you encounter terms like, "burnt-out" or "jaded", and I asked myself what exactly do those mean.  After some brief consideration the answer that I arrived at is a paramedic or EMT that has dealt with the world's sick and pseudo-sick for so long that they no longer can dredge up any empathy or compassion for their patients.  To be accurate, as a good friend pointed out, this is not only limited to EMS but also extends to nurses and physicians as well. 

Enter the Buddhist.  If you want to become physically stronger you have to stress your muscles so that they grow and develop.  Likewise, if you desire (ouch!) to become more compassionate you have to place yourself in situations where this emotion is stressed and tested: EMS.  The practicing Buddhist paramedic is tested everyday with the hoards of drug-seekers, EMS abusers, the pseudo-sick, people craving attention, uncaring medical staff, and of course uncaring family members.  Its a world that over time whittles away at one's compassion, and ability or desire to emotionally connect with patients. What better place for a Buddhist to find greater empathy and compassion?

Squad Cincuenta y Uno

I visited a Salvadorian health fair the other day.  At the entrance were two brightly colored ambulances set out as a static display with all of their associated equipment laid out for the public to view.  The two trucks looked brand spanking new and were marked "Emergency Advanced Cardiac".  Of course I was attracted to this scene like a hungry trout to a fly and rushed right over and started digging around, much to the consternation of the women running the display.

A couple of bags of IV fluid, a ratty cot that was jerry-rigged to lock into floor of the truck, and an automatic defibrillator much like you see in the malls in the United States but wrapped in plastic. One of the physicians/nurses(?) asked if I wanted to stick my arm in the automatic blood pressure cuff to see "what my number was" to determine how healthy I am. Really!!?

I'll admit that the ambulances from the outside were immaculate and very impressive, clearly nicer than what I'm used to in Atlanta, but given what they lacked in equipment would not even be allowed on the streets in the United States or Europe.  This is typical of much of the third world, parts of Latin America specifically; bright, shinny things that give the appearance of competency but with little or no substance underneath.  Someone invested a lot of money in a couple of spiffy ambulances but decided the capability or reason for them was secondary.  Why not take the same money and purchase the needed lifesaving equipment and stick it all on an old, beat-up ambulance? If I'm a seriously sick patient I don't care how nice the truck looks, only that I'm getting an advanced level of care in the back.

Maybe I'm being too critical.  Maybe they have all of drugs, monitors, airway kits, ultrasound, and other gadgets but just chose not to put them out on public display.  Having spent most of my life in and out of this part of the world and having worked in it's ERs…. I doubt it.  My regret was that I didn't take any pictures of the trucks to show my fellow medics in Atlanta.  They were seriously impressive.

For God's Sake, Stop!

My EMT partner told me a story last night of a call that he ran a few days ago.  His patient was a 12-year old girl with abdominal pain… she was two months pregnant.  Looking on, her mother…25-years old, and also her grandmother…37 years old.  I'm at a loss, you do the math.

Veteren

 We get called to a "Difficulty Breathing" patient at an Atlanta bus stop, only a mile or so from where we are in the ambulance.  These calls I normally encourage the EMTs to take, as its more often than not well within their scope of practice.

When we arrive an old, apparently homeless man sits on a bench with an oxygen mask on his face.  He's being cared for by the Atlanta Fire Department that arrived moments before.  He's thin, worn, deeply tanned.  His grey hair streaks down past his shoulders, aged tattoos color his emaciated arms. He tries to speak under the clear plastic mask that is covering his nose and mouth.  "I want to go to the VA", he wheezes out.

"You're a veteran?", I asked him.  "Damn, straight", a bit of swagger now in his voice. I look at the EMT and motion to her that I'll take this call. We help him into the back of the ambulance, collecting up his used oxygen cylinder that he's been towing around the city behind him on a little aluminum dolly.  It's empty.

In the back of the ambulance I fix his breathing issue and motion to the EMT to drive to another hospital but take our time about it.  We set off.

My new friend spent several years in the post-Vietnam era Army, having served in Europe during the Cold War.  I introduced myself as a retired "Army-guy" and then the conversation began.  We talked about places that we had known, units that we served in, and friends that were all-but forgotten.  It occurred to me that my friend probably doesn't get this sort of attention very much.  Then he told me… he's been thinking about killing himself.

The conversation turned sad and grave.  I struggled with so many things that I want to say to him.  I want to help, to listen.  In the back of my mind I made a note to let the hospital staff know, maybe they can do something for him.

In the end, I ensure that he's comfortable in the ER room.  I shake his hand and give him a subtle, little salute.  He smiles and thanks me.  Later that night I watched him exit the ER, dragging his new oxygen bottle behind him into the night.  I wish him well. 

Faces Of The Past

 

 A Turkish woman permitted me to photograph her.  I loved the serenity on her face.

I had this discussion with a physician friend of mine the other day.  The great thing about being a paramedic is that we get to see our patients in their natural environments versus having them all packaged up and brought into the ER for those to treat. Almost every call that I get I end up entering someone's home, it's an extremely personal thing and one that I give great reverence to. More times than I can count I've desperately worked on a very sick man or woman while they lay in their own bed; looking over my shoulder I can't help but notice the pictures of the dresser.  They are all the same; photos of my patient when they were in the prime of their life, healthy and happy; often times I see images of the loved ones that are standing in the room with me frantic about their sick or dying mother, father, grandparent.  For me this is a privilege, something deeply personal not easily dismissed or forgotten.

Medicine Atop A Byzantine Church

  A bin full of plaster faces for sale at a roadside tourist stand.

I toured a Turkish hospital the other day, and as I walked around I spent some time with my feelings.  The government-run hospital was crowded and a bit run-down, supplies were short but the staff was doing the best that it could with what little it had.  Nasal cannulas and oxygen masks were in short supply, so they lay draped over old, blue O2 tanks waiting for the next customer.  The lunch cart made its rounds with pots of colored liquid being ladled out onto trays.  Patients lay on ancient looking aluminum beds in the hallways and rooms; it looked like what I envisioned an eastern bloc hospital to look like during the Soviet era.

My initial emotion was something just shy of contempt.  I wondered why a modern nation had such an antiquated emergency department.  Over time I softened and realized that they were practicing the best medicine that they could given the resources that they had to work with. The Turks are desperately trying to upgrade their emergency medical capabilities, after-all that was the purpose of the conference that I was lucky enough to attend. 

I found out later that the construction of the new hospital was on hold because the intended site sits atop the ruins of a Byzantine church.  I suppose that's not an issue that we have to deal with here in the United States.  I wish them luck.

The Paramedic Process

Another Haiti photo.  I'm not sure if the scale was discarded of not, but it stood alone in the hospital street, seemingly neglected.

I've done eight straight nights on a 911 ambulance, and have spent a little time reflecting on my paramedic sprint.  I don't remember their faces, and less so their names, but I remember their ailments.  65-year old man, hypoglycemia and profoundly diaphoretic; 56-year old man, severe asthma attack that I fixed in three minutes flat; 67-year old man with new onset a-fib that I diagnosed by feeling his radial pulse; a twenty something man that I knew was lying to me about drug use just by looking at his dilated pupils.  After each run I would review the call in my head looking for mistakes, and there were plenty. I'd see a new medication that I had to look up, a symptom that I didn't catch, a blip on a 12-lead that was significant. Everything got looked up after the fact on my iPhone full of medical applications, mentally filed away for the next time that I see it.  I was intent on each run making me a better medic.  Being a paramedic is a process, I'm, seeing that now.

Seeing

  Also from Haiti.  A woman walks along the street carrying her child closely to her.  The little feet sticking our from the blanket make me sad in a way.

In the very early hours of the morning I sat parked in an ambulance at a truck stop and starred into the window of the late-night restaurant.  I had little else to look at aside from my watch, counting the hours until I got off from work and could go home to my own bed. 

Through the window I watched a very heavy-set African American woman, dressed in the cheap, red uniform, push a broom across the floor. If I were any place else I wouldn't have given it a second thought, but here I was a captive audience and couldn't help reflect on what I was witnessing.  Dozens of questions flashed through my mind as I watched the thirty-something woman go about her manual tasks.  Was this where she envisioned fifteen years ago that her life would end up?  What does she dream of, aspire to, or has she resigned her life to where she is now? I couldn't help myself and tried to recreate her life in my mind, I wanted to project myself into her reality.  What were her disappointments, her victories?  What motivates her?  Where, if at all, would she go back and change her life.  Above all, was she happy? The questions kept coming and coming as I watched her through the grimy window.

I suppose my lesson was that everyone has a story, a life, a past, and a present.  I for one am guilty of going through my days at times oblivious to those around me.  I see people but I truly do not "see' them; the man crossing the street with his young son or the woman pushing the broom late at night.  I suppose in many ways this is why I like 911 so much.  For a brief moment in time it's just me in the back of the ambulance with another person, a chance to get to know someone on a deeper more compassionate level, other than just simply seeing them.     

Not A Good Night For Humanity

 A photo from Haiti. A daughter watches over her father while waiting outside of the hospital "Emergency Room" tent in the heat of the day.

A 911 call came to us last night, respond to a convenience store only a few blocks from where my EMT partner and I were sitting.  Within moments as we arrive to find four squad cars rocketing in and out of the parking lot, one of the officers is eagerly motioning for us to come inside and attend to the patient.  I remember thinking that these guys are amp-ed up, this level of activity is normally reserved for gunshots.

An older Asian woman sits slumped on a stool with an obvious laceration under her eye.  She's in quite a bit emotional and or physical pain.  The story goes that a man came into the store, got himself a large cup of hot coffee and threw it onto the attendant's face.  He then viciously punched her in the eye, grabbed the money out of the open drawer and fled through the front door. 

As my EMT treated the lady I couldn't help but be moved by the degree of violence and inhumanity that had just taken place.  Why would anyone do this and moreover, what was going through their mind?  A question that I've wrestled with lately is, does everyone in the world consider themselves "deep-down a good person", conversely are there people that simply know that they are at-root evil and devoid of humanity and kindness?  How can someone commit such a barbaric act and still view themselves as a "good person"?  Sadly,  I realized my answer last night.

Triage Notes

Now a common sight on the Haitian streets.

Not all emergencies are created equal.  The triage area of the Haitian hospital I've been working at is a busy and often ugly place.  An elderly lady is vomiting frank blood into a clear plastic bag, a man has large pieces of his face missing and is bleeding badly onto a filthy rag.  Next to them an agitated twenty-something man sits clutching a slightly angulated little finger… I know it was angulated because I looked REALLY closely.  Mr. Hurt Pinky is motioning for me to treat his finger, his eyes beam impatience and frustration that he is not being promptly taken care of.  "Why am I not at the head of the line?" I don't speak Creole so I point to the lady with the bag-o-blood in her feeble fingers and raise my hands in the international "are you serious?" gesture.  He backs down… for a few minutes.  This is "triage"… isn't that a French word, similar to Creole, that means bags of blood and missing faces come before hurt pinkies?

Not The Sole Providence Of The Strong

 A mother holds her child in one of the hospital's pediatric tents

Again, last night I worked in the hospital's emergency room, my task was to suture lacerations as they came in; I was certainly not at a loss for work.  I trolled the triage area looking for anyone with a bloody dressing; a quick examination and I would usher them into my little work area within the tent.

Sitting on the pew-like benches was a tiny girl atop her father's lap.  She held a stained piece of cloth over her forehead with her own hand.  She couldn't have been more than 5-years old.  As I took a gentle look I silently prayed that I would be able to stick a Band-Aid on it and send her happily on her way.  This was not the case, she had a 4 cm "lac" to her forehead that was going to require a few interrupted sutures.  I cringed at the thought of having to cause this innocent little girl further pain in her life. 

I took them both back into the tent and laid her down on a worn cot so that I could get a better look using my headlamp, often the only light source that we have at night.  She was stoic, unafraid, staring at me with a look of curiosity, almost daring me to assault her bravery.  I wanted to sit a bit with her before I had to inject her with a syringe of lidocaine which is often the most painful part of the procedure.  We smiled at one another, she played with my light, and I patted her on the head.  The interpreter explained to her that it was going to sting a bit, but try to remain still.

She closed her eyes as the steel needle sunk into the gaping wound,  not so much as a wince.  Her face remained calm and passive almost as if she were asleep.  Her bravery penetrated me, this 5-year old girl, in the face of something that would make me cringe, laid there determined to be brave. 

It took only a few minutes to place the three sutures, but not even so much as a whimper.  In the end I touched her forehead and told her "finished"; her eyes fluttered open… a smile from me to her. Little fingers reached up to explore the new dressing.  Her father thanked me and he scooped her up in her arms and disappeared down the dark street.  Bravery is not the sole providence of the strong.

Watching

I've spent the last several nights working in a Haitian emergency room along side some very talented and caring physicians and nurses.  Last night an unconscious man was brought in by car and carefully laid on a stretcher outside our rain-soaked tent. Dressed in mud-soaked jeans and a worn t-shirt he had simply collapsed while crossing the street. His family brought him to us.  There was no neurologic function, his blood pressure was very high, and his heart rate was slow; all indications that he had burst a blood vessel in his head.  There was nothing that we could do for the man.

The family listened intently as the news was passed through a Creole translator.  They asked if there was some machine that we could put him on, some medication that they could procure that might give him a chance to come back to them. "We're sorry, there is really nothing we can do".  The family went away to get some other clothes so that their father/friend/husband didn't have to die in wet jeans and a soiled t-shirt.

He lay there and I watched.  All night, breath after breath… I watched.  I watched as the man took his last breath, nothing more than a small gasp really.  It stopped raining; I left the tent to get some coffee.

Random Thoughts From A Himalayan Cave

Door knocker on the door of a Chicago Chinese restaurant

I've spent the last several days pretty much by myself, which is generally a good thing for me. I'm not a very social person, and would do very well in a Himalayan cave meditating for eight years. To that end, here are some random thoughts.

- I don't like zoos. While I understand the purposes; money, research, and display. I think we as humans can do better.

- BRicks (Bike-Run, ick!) workouts are the bane of most triathletes, and I dislike them as much as anybody, but they're a necessary evil for me this year as my bike-to-run transitions suck.

- I need to go to the zendo tomorrow morning and sit… a lot.

- Matt Damon's Green Zone is a good movie, and I enjoyed it very much. I like Matt as an actor.

- Paramedics need to think clinically and have a good medical reason to "collar and board" a patient. Mechanism alone is not enough.

- Chain sushi restaurants tend to be not very authentic and not very good.

- I like Barnes & Noble's electronic book reader, the Nook very much. I'm an Amazon Kindle owner, but am considering trading up.

- I don't understand why funeral processions have the right of way and are allowed to inconvenience hundreds of people along the route. Certainly this wasn't the deceased's last wish? I want to pass the deceased in my car, not drive over him.

- I need to go fly fishing but the Chattahoochee River is too swollen with all of the recent rains. I'm not a good enough fly fisherman to lure a trout out of a fast-flowing, murky river.

- I need to call my parents.

Just Live A Good Life

I had a conversation with a life-long city EMS medic a while back and we were speaking about traveling. He told me that during his fifteen years of EMS that his one great regret was that he had never really ventured very far away from his native city, certainly not overseas. We exchanged stories over coffee and he confided in me that he was actually envious of my life; that I spend it traveling from one distant land to another, having the chance to see so many places and their people.

I've been down this road before and cautioned my friend that everything has it's downside. He looked at me quizzically as I pointed out that he has the luxury of coming home every night to his family, his wife and kids, never missing a single birthday, a ball game, or a school play. In many ways it was I who was envious of his life, doing what he loved and sleeping in his own bed every night.

As the morning coffee ended I think that each of us realized that we were both doing exactly what we wanted to do, however no life is perfect. Everything has it's upsides and its downs, and not everyone's DNA is programed to explore the world and conversely not to remain static. Each has it's own goals and aspirations, neither bad nor good, just to live a good life.

Fist-Bumps and Missing Teeth

A long day today, I spent most of it in a hospital west of the city looking at a variety of post-earthquake patients who had lost limbs.  One little boy in particular captured my attention.  He had recently lost his right leg above the knee and was learning to use his new crutches.  From what I could gather he had lost all of his family; he was 9-years old and alone in the world. I saw him and we immediately bonded, he awkwardly shuffled his crutches around so he could return my fist-bump.  He got it done; his name was Sebastian. 

As we stood there side-by-side in the sticky Haitian heat; he looked up at me and smiled, he was missing his two front teeth. I took comfort in the fact that they fell out naturally and finally there was something that was not a result of the earthquake.  I remember thinking, if there were any kid that I would adopt and take away from this place it would be my resilient little hero balancing on a set of crutches next to me.  My thoughts went back to the starfish parable; I can save this one.

In the end, we exchanged fist-bumps and toothless smiles.  I silently said a little blessing wishing Sabastian well and walked away.  I want to go home.

A Compasionate Moment

A husband sleeps next to his wife's bed as she slowly recovers from her wounds. It's the family members that are providing the vast majoring of the care here in post-earthquake Haiti.

Late at night I walk through the hospital checking on patients as they sleep on stained cots, their family members are laying on the ground next to them. I'm constantly approached by panicked family members begging me in very broken English to come and look at their loved ones. They grab at my hand and plead, "Doctor, doctor...please come. Come please". I fight to be compassionate, but the urge to dismiss their concerns is strong. I follow a "real physician" into the shadows of a darkened tent, a single candle burns on a rickety table covered with medical refuse from the day before. I watch the physician deal with the panicked father/son/brother as it's evident that the cause of his angst was an IV bag that has run it's course. The physician smiles and pats the man's shoulder telling him as best that he can through a smile and a gesture that it's OK. The man relaxes and I'm standing there in awe. Certainly the physician is medically talented, but to be able to muster that sort of focused compassion amidst all of the suffering was truly inspiring for me. Simply awesome.